Thromboembolism in patients undergoing thoracotomy

doi:10.1016/0003-4975(93)91151-C

The Annals of Thoracic Surgery

Volume 56, Issue 2, August 1993, Pages 223-227

https://doi.org/10.1016/0003-4975(93)91151-C Get rights and content

Abstract

To determine the incidence of thromboembolism in relation to thoracotomy, 77 patients undergoing pulmonary resection were prospectively studied up to 30 days postoperatively for deep venous thrombosis and pulmonary embolism. Overall, 20 of 77 patients (26%) had thromboembolic events during their hospitalization. Four deep venous thromboses and 1 pulmonary embolism were detected in 5 of 77 patients preoperatively for an incidence of 6%. Postoperative thromboembolism was detected in 15 of 77 (19%). deep venous thrombosis in 11 (14%) and pulmonary embolism in 4 (5%). No postoperative thromboembolisms occurred in the 17 patients receiving preoperative aspirin or ibuprofen, whereas they did occur in 25% of the remainder ( $15 / 60$ ). Thromboembolism after pulmonary resection was more frequent with bronchogenic carcinoma than with metastatic cancer or benign disease ( $15 / 19 [25 %] versus 0 / 18 [0 %]; p < 0.01$ ), adenocarcinoma compared with other types of carcinoma ( $11 / 25 [44 %] versus 4 / 34 [12 %]; p < 0.0004$ ), large primary lung cancer (>3 cm in diameter) compared with smaller lesions ( $9 / 19 [47 %] versus 6 / 40 [15 %]; p < 0.0001$ ), stage II compared with stage I ( $7 / 14 [50 %] versus 7 / 34 [21 %]; p < 0.004$ ), and pneumonectomy or lobectomy compared with segmentectomy and wedge resection ( $14 / 49 [29 %] versus 1 / 28 [4 %]; p < 0.005$ ). Three of 4 patients with thromboembolism detected preoperatively had operation within the previous year. Postoperative pulmonary embolism was fatal in 1 of 4 (25%) and accounted for the one death. These results suggest patients undergoing thoracotomy for lung cancer, especially adenocarcinoma, should be considered for thromboembolic prophylaxis.

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Cited by (102)

Joint 2022 European Society of Thoracic Surgeons and The American Association for Thoracic Surgery guidelines for the prevention of cancer-associated venous thromboembolism in thoracic surgery
2023, Journal of Thoracic and Cardiovascular Surgery
Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a potentially fatal but preventable postoperative complication. Thoracic oncology patients undergoing surgical resection, often after multimodality induction therapy, represent among the highest risk groups for postoperative VTE. Currently there are no VTE prophylaxis guidelines specific to these thoracic surgery patients. Evidenced-based recommendations will help clinicians manage and mitigate risk of VTE in the postoperative period and inform best practice.
These joint evidence-based guidelines from The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons aim to inform clinicians and patients in decisions about prophylaxis to prevent VTE in patients undergoing surgical resection for lung or esophageal cancer.
The American Association for Thoracic Surgery and the European Society of Thoracic Surgeons formed a multidisciplinary guideline panel that included broad membership to minimize potential bias when formulating recommendations. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE Evidence-to-Decision frameworks, which were subject to public comment.
The panel agreed on 24 recommendations focused on pharmacological and mechanical methods for prophylaxis in patients undergoing lobectomy and segmentectomy, pneumonectomy, and esophagectomy, as well as extended resections for lung cancer.
The certainty of the supporting evidence for the majority of recommendations was judged as low or very low, largely due to a lack of direct evidence for thoracic surgery. The panel made conditional recommendations for use of parenteral anticoagulation for VTE prevention, in combination with mechanical methods, over no prophylaxis for cancer patients undergoing anatomic lung resection or esophagectomy. Other key recommendations include: conditional recommendations for using parenteral anticoagulants over direct oral anticoagulants, with use of direct oral anticoagulants suggested only in the context of clinical trials; conditional recommendation for using extended prophylaxis for 28 to 35 days over in-hospital prophylaxis only for patients at moderate or high risk of thrombosis; and conditional recommendations for VTE screening in patients undergoing pneumonectomy and esophagectomy. Future research priorities include the role of preoperative thromboprophylaxis and the role of risk stratification to guide use of extended prophylaxis.
Venous Thromboembolism in Surgical Lung Cancer Patients: A Provincial Population-Based Study
2022, Annals of Thoracic Surgery
Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in surgical patients. Thoracic surgery patients are at increased risk due to inherent technical and disease-specific factors. Other surgical specialties have adopted postdischarge extended VTE prophylaxis; however evidence is scarce in thoracic surgery. This study aims to identify VTE risk factors and associated mortality among surgical lung cancer patients.
Using administrative databases all patients in the province of Ontario undergoing lung cancer surgery from 2007 to 2017 were identified. Logistic regression identified VTE risk factors at 90 days and 1 year postoperatively. A flexible parametric survival analysis compared mortality and survival up to 5 years after surgery between patients with and without VTE.
Of 65,513 patients diagnosed with lung cancer, 12,626 (19.3%) underwent surgery. VTE incidence at 90 days and 1 year postoperatively was 1.3% and 2.7%, respectively. Open and more extensive resections carried an increased VTE risk, with pneumonectomy conferring the highest risk (odds ratio, 2.36; P < .001). Stage III and IV disease carried a 3.19 and 4.97 times higher risk of VTE, respectively, compared with stage I (P < .001). The hazard ratio for mortality at 1 year for patients with VTE was 2.01 (P < .001). Patients suffering a VTE had reduced 5-year survival.
Patients undergoing pneumonectomy and those with advanced stage have an increased VTE risk. Patients suffering a thrombotic complication have an increased risk of mortality and decreased 5-year survival. Accordingly strategies to reduce VTE risk should be considered in patients undergoing high-risk operations to reduce the mortality of VTEs.
Postoperative complications after major lung resection
2019, Revue des Maladies Respiratoires
L’avènement des techniques minimalement invasives a permis une ouverture plus large des indications chirurgicales avec notamment des patients plus âgés et présentant un nombre plus important de comorbidités. Le taux de complications postopératoire est cependant resté stable.
On les définit comme une variation par rapport au déroulé habituel. Elles surviennent dans 30 % des interventions mais restent majoritairement mineures. La mortalité globale d’après les séries disponibles est estimée entre 2 % et 3 %. On distingue ainsi : (1) les complications précoces survenant dans les 24 première heures, regroupant les complications chirurgicales « classiques » ainsi que d’autres plus spécifiques à cette chirurgie d’organe ; (2) les complications survenant lors de l’hospitalisation (au cours des 3 premiers mois) comprennent les évènements infectieux avec une prépondérance des pneumopathies, des infections sur site opératoire, des complications bronchiques, pleurales ou cardiologiques ; (3) les complications tardives dominées par les douleurs chroniques. La lobectomie reste l’intervention standard, que nous prenons comme modèle pour la description des complications. La pneumonectomie représente une chirurgie à part notamment dans sa gestion péri- et postopératoire.
La chirurgie d’exérèse majeure a bénéficié des progrès des voies minimalement invasives et des circuits de réhabilitation précoces. On note l’apparition cependant de nouvelles complications spécifiques à ces voies d’abord.
The advent of the minimally invasive techniques has allowed an expansion of the indications for thoracic surgery, particularly in older patients and those with more comorbidities. However, the rate of postoperative complications has remained stable.
Postoperative complications are defined as any variation from the normal course. They occur in 30% but majority of them are minor. The 30-day mortality rate for lung resection varies range between 2 % and 3% in the literature. Complications can be classified as: (1) early (occurring in the first 24 hours) including both “generic” surgical complications (especially postoperative bleeding) and complications more specific to lung surgery (Acute respiratory syndrome, atelectasis); (2) in-hospital complications and those occurring during the first 3 months; these are dominated by infectious events in particular pneumonia but also bronchial (bronchopleural fistula), pleural (pneumothorax, hydrothorax) or cardiac complications; (3) late complications are dominated by chronic pain, affecting 60% of patients having a thoracotomy at three months. Lobectomy is the most common lung resection. Pneumonectomy is a distinct procedure requiring a specific peri- and postoperative management. Right pneumonectomy is associated with a higher risk with a treatment related-mortality ranging between 7 and 10%.
Major lung resection has benefited from minimally invasive approaches and fast track to surgery. However, it is important to note the occurrence of new and specific complications related to those news surgical access.
Incidence, risk factors, and outcomes of venous thromboembolism after oncologic surgery: A systematic review and meta-analysis
2019, Thrombosis Research
The risk and prognosis of VTE associated with oncologic surgery need to be quantified to guide patient management. We aimed to examine the availability of data and to report the incidence of venous thromboembolism (VTE) in cancer patients after surgery, as well as the clinical outcomes of VTE following oncologic surgery.
We searched multiple databases for terms related to VTE after oncologic surgery from inception to November 1, 2017. A random-effects meta-analysis was done to calculate the pooled incidence of VTE.
Of the 8611 citations identified, 136 studies including 1,481,659 patients met the eligibility criteria. The overall incidence of VTE was estimated to be 2.3% (95% CI 2.1–2.5). Bone and soft tissue cancer (10.6%, 95% CI 2.9–18.2) and lung cancer (8.1%, 95% CI 3.7–12.6) were associated with the highest and second highest risk of postoperative VTE, respectively. Age (standardized mean difference [SMD] = 0.46, 95% CI 0.40–0.53; I² = 93.8%), radiation (OR 1.29, 95% CI 1.03–1.62; I² = 34.6%), transfusion (OR 1.96, 95% CI 1.48–2.59; I² = 57.0%), and operative time (SMD = 1.12, 95% CI 1.07–1.16; I² = 100%) were possible risk factors for postoperative VTE. Patients with VTE versus those without had increased odds of all-cause fatal events (11.15, 95% CI 4.07–30.56; I² = 92.0%).
The risk of VTE after oncologic surgery remains high, and this risk varied according to the cancer type, study region, surgical location, and thromboprophylactic strategy. VTE is associated with increased mortality at the early stage of cancer surgery.
Postoperative Imaging and Complications in Resection of Lung Cancer
2018, Seminars in Ultrasound, CT and MRI
Citation Excerpt :
The lobar airways and vessels will have abnormal orientation and tapering or occlusion34 (Fig. 3). Focal or multifocal occlusion of the pulmonary arterial bed from venous thromboembolism is reported in 5% of postthoracotomy patients.42,43 Risk factors include primary lung cancer, tumor diameter >3 cm, and lobectomy or pneumonectomy.42
Surgical resection offers the best hope of cure for patients with operable early-stage lung cancer. Wedge resection, segmentectomy, lobectomy, or pneumonectomy may be performed depending on the size and location of the tumor. Radiologists must be familiar with the types of surgical resection utilized in the treatment of lung carcinoma and with their normal and abnormal postsurgical appearance on imaging studies. Prompt identification of postoperative complications on imaging is essential to appropriate patient management and helps to determine when additional intervention is warranted.
Postdischarge venous thromboembolic complications following pulmonary oncologic resection: An underdetected problem
2016, Journal of Thoracic and Cardiovascular Surgery
To determine the prevalence of delayed postoperative venous thromboembolism (VTE) in patients undergoing oncologic lung resections, despite adherence to current in-hospital VTE prophylaxis guidelines.
Patients undergoing lung resection for malignancy in 2 tertiary-care centers were recruited between June 2013 and December 2014. All patients received guideline-based VTE prophylaxis until hospital discharge. Patients underwent computed tomography chest angiography with pulmonary embolism (PE) protocol and bilateral lower extremity venous Doppler ultrasonography at 30 ± 5 days after surgery to determine the incidence of postoperative VTE. Univariate analysis was used to compare the VTE and non-VTE groups.
A total of 157 patients were included, 45.9% were men with a mean age of 66.7 years. VTE prevalence was 12.1% with a total of 19 VTE events, including 14 PEs (8.9%), 3 deep venous thromboses (DVTs) (1.9%), 1 combined PE/DVT, and 1 massive left atrial thrombus originating from the pulmonary vein stump after pulmonary lobectomy. PE events occurred in the operated lung 64% of the time and 4 patients (21.1%) were symptomatic at diagnosis. The 30-day mortality rate of VTE events was 5.2%, with 1 patient who died secondary to massive in situ ipsilateral PE following readmission to the hospital. Univariate analysis did not demonstrate significant differences between the VTE and non-VTE populations with regard to baseline characteristics.
Despite adherence to in-hospital standard prophylaxis guidelines, VTE events are frequent, often asymptomatic, and with associated significant morbidity and mortality. More research into the potential role of predischarge screening and extended prophylaxis is warranted.

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^☆: Presented at the Twenty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1993.

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Original articleThromboembolism in patients undergoing thoracotomy☆

Abstract

Chest

Am J Surg

Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic, and urologic surgery

N Engl J Med

A 30-year survey of pulmonary embolism verified at autopsy: an analysis of 1274 surgical patients

Br J Surg

Current operative mortality associated with elective resection for lung cancer

Can J Surg

Multiple pulmonary microemboli complicating pneumonectomy

Ann Thorac Surg

Pulmonary embolism and lung cancer: a postmortem study of 482 patients

Chest

A new international staging system for lung cancer

Chest

Radiological (scintigraphic) evaluation of patients with suspected pulmonary thromboembolism

JAMA

Prevention of venous thrombosis and pulmonary embolism

Original article
Thromboembolism in patients undergoing thoracotomy☆